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Copelyn J, Eley B, Cox H, Workman L, Dheda K, Nicol MP, Zar HJ. Treatment Response in Pediatric Pulmonary Tuberculosis-A Prospective Longitudinal Study. J Pediatric Infect Dis Soc 2022; 11:329-336. [PMID: 35462407 PMCID: PMC9302696 DOI: 10.1093/jpids/piac029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/28/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Data are limited on the resolution of symptoms and signs in children treated for pulmonary tuberculosis (PTB) and whether this resolution differs from children with other lower respiratory tract infections (LRTIs). METHODS A prospective study of children ≤ 15 years presenting with features suggestive of PTB was performed. Clinical, microbiological, and radiological investigations were done at enrollment. Symptoms and clinical features were measured 1, 3, and 6 months after enrollment. Participants were categorized into 3 groups based on National Institutes of Health consensus definitions: confirmed PTB, unconfirmed PTB, and unlikely PTB (children with other LRTIs). Univariable and multivariable logistic regression modeling was used to investigate predictors of persistence of symptoms or signs. RESULTS Among 2019 participants, there were 427 (21%) confirmed, 810 (40%) unconfirmed, and 782 (39%) with unlikely PTB. Of 1693/2008 (84%) with cough and 1157/1997 (58%) with loss of appetite at baseline, persistence at 3 months was reported in 24/1222 (2%) and 23/886 (3%), respectively. Of 934/1884 (50%) with tachypnoea and 947/1999 (47%) with abnormal auscultatory findings at baseline, persistence at 3 months occurred in 410/723 (57%) and 216/778 (28%), respectively. HIV infection and abnormal baseline chest radiography were associated with persistence of symptoms or signs at month 3 (adjusted odds ration [aOR] 1.6; 95% confidence interval [CI]: [1.1, 2.3] and aOR 2.3; 95% CI: [1.5, 3.3], respectively]. The resolution of symptoms and signs was similar across categories. CONCLUSIONS Symptoms resolved rapidly in most children with PTB, but signs resolved more slowly. The pattern and resolution of symptoms or signs did not distinguish children with PTB from those with other LRTIs.
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Affiliation(s)
- Julie Copelyn
- Corresponding Author: Julie Copelyn, MPhil, MMed, MBBS, Department of Paediatric Infectious Diseases, Red Cross War Memorial Children’s Hospital, Klipfontein Road, Cape Town, 7700, South Africa. E-mail:
| | - Brian Eley
- Paediatric Infectious Diseases Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa,Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Helen Cox
- Division of Medical Microbiology, Wellcome Centre for Infectious Disease Research and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Lesley Workman
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa,South African Medical Research Council Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa,Department of Immunology and Infection, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Mark P Nicol
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa,Department of Biomedical Sciences, Division of Infection and Immunity, University of Western Australia, Perth, Australia
| | - Heather J Zar
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa,South African Medical Research Council Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
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Kazibwe A, Twinomugisha F, Musaazi J, Nakaggwa F, Lukanga D, Aleu P, Kiyemba T, Nkolo A, Kirirabwa NS, Lopez DBF, Birabwa E, Dejene S, Zawedde-Muyanja S. Comparative yield of different active TB case finding interventions in a large urban TB project in central Uganda: a descriptive study. Afr Health Sci 2021; 21:975-984. [PMID: 35222557 PMCID: PMC8843286 DOI: 10.4314/ahs.v21i3.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Systematic screening for TB among patients presenting to care and among high risk populations is recommended to improve TB case finding. We aimed to describe the comparative yield of three TB screening approaches implemented by a large urban TB project in central Uganda. METHODS We abstracted data on the screening cascade from 65 health facilities and their surrounding communities (numbers screened, with presumptive TB, receiving a diagnostic test and diagnosed with TB) from the different clinic and community TB registers. RESULTS From January 2018 to December 2019, 93,378 (24%) of all patients screened at health facilities had presumptive TB; 77,381 (82.9%) received a diagnostic test and 14,305 (18.5%) were diagnosed with TB. The screening yield (the number of patients diagnosed with TB out of all patients screened) was 0.3% and was three times higher among men than women (0.6% vs 0.2% p<0.01). During targeted community screening interventions, 9874 (21.1%) of all patients screened had presumptive TB; 7034 (71.2%) of these received a diagnostic test and 1699 (24.2%) were diagnosed with TB. The screening yield was higher among men, (3.7% vs 3.3% p<0.01) and highest among children 0-14 (4.8% vs 3.2% p<0.01). CONCLUSION Targeted community TB screening interventions improve access to TB diagnosis for men and children 0-14 years.
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Affiliation(s)
- Andrew Kazibwe
- The AIDS Support Organization, Kampala, Uganda.,USAID/Defeat TB Project, University Research Co. LLC, Kampala, Uganda
| | - Fred Twinomugisha
- USAID/Defeat TB Project, University Research Co. LLC, Kampala, Uganda.,The Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joseph Musaazi
- The Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Florence Nakaggwa
- USAID/Defeat TB Project, University Research Co. LLC, Kampala, Uganda
| | | | - Phillip Aleu
- USAID/Defeat TB Project, University Research Co. LLC, Kampala, Uganda
| | - Timothy Kiyemba
- USAID/Defeat TB Project, University Research Co. LLC, Kampala, Uganda
| | - Abel Nkolo
- USAID/Defeat TB Project, University Research Co. LLC, Kampala, Uganda
| | | | | | | | | | - Stella Zawedde-Muyanja
- USAID/Defeat TB Project, University Research Co. LLC, Kampala, Uganda.,The Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
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3
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Dixon J, Tameris M. A disease beyond reach: nurse perspectives on the past and present of tuberculosis control in South Africa. ANTHROPOLOGY SOUTHERN AFRICA 2018. [DOI: 10.1080/23323256.2018.1526096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Justin Dixon
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michèle Tameris
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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4
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Jenum S, Selvam S, Jesuraj N, Ritz C, Hesseling AC, Cardenas V, Lau E, Doherty TM, Grewal HMS, Vaz M. Incidence of tuberculosis and the influence of surveillance strategy on tuberculosis case-finding and all-cause mortality: a cluster randomised trial in Indian neonates vaccinated with BCG. BMJ Open Respir Res 2018; 5:e000304. [PMID: 30397482 PMCID: PMC6203048 DOI: 10.1136/bmjresp-2018-000304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/14/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction Accurate tuberculosis (TB) incidence and optimal surveillance strategies are pertinent to TB vaccine trial design. Infants are a targeted population for new TB vaccines, but data from India, with the highest global burden of TB cases, is limited. Methods In a population-based prospective trial conducted between November 2006 and July 2008, BCG-vaccinated neonates in South India were enrolled and cluster-randomised to active or passive surveillance. We assessed the influence of surveillance strategy on TB incidence, case-finding rates and all-cause mortality. Predefined criteria were used to diagnose TB. All deaths were evaluated using a verbal autopsy. Results 4382 children contributed to 8164 person-years (py) of follow-up (loss to follow-up 6.9%); 749 children were admitted for TB evaluation (active surveillance: 641; passive surveillance: 108). The TB incidence was 159.2/100 000 py and the overall case-finding rate was 3.19 per 100 py (95% CI 0.82 to 18.1). Whereas, the case-finding rate for definite TB was similar using active or passive case finding, the case-finding rate for probable TB was 1.92/100 py (95% CI 0.83 to 3.78) with active surveillance, significantly higher than 0.3/100 py (95% CI 0.01 to 1.39, p=0.02) with passive surveillance. Compared to passive surveillance, children with active surveillance had decreased risk of dying (OR 0.68, 95%CI 0.47 to 0.98) which was mostly attributable to reduction of death from pneumonia/respiratory infections (OR 0.34, 95%CI 0.14 to 0.80). Conclusion We provide reliable estimates of TB incidence in South Indian children <2 years of age. Active surveillance increased the case-finding rates for probable TB and was associated with reduced all-cause mortality.
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Affiliation(s)
- Synne Jenum
- Department of Clinical Science, University of Bergen, Bergen N-5021, Norway.,Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Sumithra Selvam
- Division of Epidemiology, Biostatistics and Population Health, St. John's Research Institute, Bangalore, Koramangala, India
| | - Nelson Jesuraj
- St. John's Research Institute, Bangalore, Koramangala, India
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Anneke C Hesseling
- Desmond Tutu TB Center, Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Vicky Cardenas
- Aeras, Rockville, Maryland, USA (Present affiliation: Aurum Institute, Rockville, Maryland, USA)
| | | | | | - Harleen M S Grewal
- Department of Clinical Science, University of Bergen, Bergen N-5021, Norway.,Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - Mario Vaz
- Division of Health and Humanities, St. John's Research Institute, Bangalore, Koramangala, India
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Mhimbira FA, Cuevas LE, Dacombe R, Mkopi A, Sinclair D. Interventions to increase tuberculosis case detection at primary healthcare or community-level services. Cochrane Database Syst Rev 2017; 11:CD011432. [PMID: 29182800 PMCID: PMC5721626 DOI: 10.1002/14651858.cd011432.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pulmonary tuberculosis is usually diagnosed when symptomatic individuals seek care at healthcare facilities, and healthcare workers have a minimal role in promoting the health-seeking behaviour. However, some policy specialists believe the healthcare system could be more active in tuberculosis diagnosis to increase tuberculosis case detection. OBJECTIVES To evaluate the effectiveness of different strategies to increase tuberculosis case detection through improving access (geographical, financial, educational) to tuberculosis diagnosis at primary healthcare or community-level services. SEARCH METHODS We searched the following databases for relevant studies up to 19 December 2016: the Cochrane Infectious Disease Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library, Issue 12, 2016; MEDLINE; Embase; Science Citation Index Expanded, Social Sciences Citation Index; BIOSIS Previews; and Scopus. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and the metaRegister of Controlled Trials (mRCT) for ongoing trials. SELECTION CRITERIA Randomized and non-randomized controlled studies comparing any intervention that aims to improve access to a tuberculosis diagnosis, with no intervention or an alternative intervention. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility and risk of bias, and extracted data. We compared interventions using risk ratios (RR) and 95% confidence intervals (CI). We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included nine cluster-randomized trials, one individual randomized trial, and seven non-randomized controlled studies. Nine studies were conducted in sub-Saharan Africa (Ethiopia, Nigeria, South Africa, Zambia, and Zimbabwe), six in Asia (Bangladesh, Cambodia, India, Nepal, and Pakistan), and two in South America (Brazil and Colombia); which are all high tuberculosis prevalence areas.Tuberculosis outreach screening, using house-to-house visits, sometimes combined with printed information about going to clinic, may increase tuberculosis case detection (RR 1.24, 95% CI 0.86 to 1.79; 4 trials, 6,458,591 participants in 297 clusters, low-certainty evidence); and probably increases case detection in areas with tuberculosis prevalence of 5% or more (RR 1.52, 95% CI 1.10 to 2.09; 3 trials, 155,918 participants, moderate-certainty evidence; prespecified stratified analysis). These interventions may lower the early default (prior to starting treatment) or default during treatment (RR 0.67, 95% CI 0.47 to 0.96; 3 trials, 849 participants, low-certainty evidence). However, this intervention may have may have little or no effect on treatment success (RR 1.07, 95% CI 1.00 to 1.15; 3 trials, 849 participants, low-certainty evidence), and we do not know if there is an effect on treatment failure or mortality. One study investigated long-term prevalence in the community, but with no clear effect due to imprecision and differences in care between the two groups (RR 1.14, 95% CI 0.65 to 2.00; 1 trial, 556,836 participants, very low-certainty evidence).Four studies examined health promotion activities to encourage people to attend for screening, including mass media strategies and more locally organized activities. There was some increase, but this could have been related to temporal trends, with no corresponding increase in case notifications, and no evidence of an effect on long-term tuberculosis prevalence. Two studies examined the effects of two to six nurse practitioner educational sessions in tuberculosis diagnosis, with no clear effect on tuberculosis cases detected. One trial compared mobile clinics every five days with house-to-house screening every six months, and showed an increase in tuberculosis cases.There was also insufficient evidence to determine if sustained improvements in case detection impact on long-term tuberculosis prevalence; this was evaluated in one study, which indicated little or no effect after four years of either contact tracing, extensive health promotion activities, or both (RR 1.31, 95% CI 0.75 to 2.30; 1 study, 405,788 participants in 12 clusters, very low-certainty evidence). AUTHORS' CONCLUSIONS The available evidence demonstrates that when used in appropriate settings, active case-finding approaches may result in increase in tuberculosis case detection in the short term. The effect of active case finding on treatment outcome needs to be further evaluated in sufficiently powered studies.
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Affiliation(s)
- Francis A Mhimbira
- Ifakara Health Institute (IHI)Bagamoyo Research and Training Center (BRTC)PO Box 74BagamoyoTanzania
- Swiss Tropical and Public Health InstituteBaselSwitzerland
- University of BaselBaselSwitzerland
| | - Luis E. Cuevas
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolUKL3 5QA
| | - Russell Dacombe
- Liverpool School of Tropical MedicineDepartment of International Public HealthPembroke PlaceLiverpoolUKL3 5QA
| | - Abdallah Mkopi
- Ifakara Health Institute (IHI)Impact Evaluation, Health Systems Interventions & Policy TranslationPO Box 78373Dar es SalaamTanzania
| | - David Sinclair
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolUKL3 5QA
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Concepcion NDP, Laya BF, Andronikou S, Daltro PAN, Sanchez MO, Uy JAU, Lim TRU. Standardized radiographic interpretation of thoracic tuberculosis in children. Pediatr Radiol 2017; 47:1237-1248. [PMID: 29052771 PMCID: PMC5574960 DOI: 10.1007/s00247-017-3868-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 04/09/2017] [Indexed: 11/30/2022]
Abstract
There is a lack of standardized approach and terminology to classify the diverse spectrum of manifestations in tuberculosis. It is important to recognize the different clinical and radiographic patterns to guide treatment. As a result of changing epidemiology, there is considerable overlap in the radiologic presentations of primary tuberculosis and post-primary tuberculosis. In this article we promote a standardized approach in clinical and radiographic classification for children suspected of having or diagnosed with childhood tuberculosis. We propose standardized terms to diminish confusion and miscommunication, which can affect management. In addition, we present pitfalls and limitations of imaging.
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Affiliation(s)
- Nathan David P. Concepcion
- 0000 0004 0571 4942grid.416846.9Section of Pediatric Radiology, Institute of Radiology, St. Luke’s Medical Center, Bonifacio Global City, Taguig City, Philippines ,0000 0004 0571 4942grid.416846.9Section of Pediatric Radiology, Institute of Radiology, St. Luke’s Medical Center, Quezon City, Philippines
| | - Bernard F. Laya
- 0000 0004 0571 4942grid.416846.9Section of Pediatric Radiology, Institute of Radiology, St. Luke’s Medical Center, Bonifacio Global City, Taguig City, Philippines ,0000 0004 0571 4942grid.416846.9Section of Pediatric Radiology, Institute of Radiology, St. Luke’s Medical Center, Quezon City, Philippines
| | - Savvas Andronikou
- Department of Paediatric Radiology, Bristol Royal Hospital for Children and the University of Bristol, Bristol, UK.
| | - Pedro A. N. Daltro
- Section of Pediatric Radiology, Clínica de Diagnóstico por Imagem, Rio de Janeiro, Brazil
| | - Marion O. Sanchez
- 0000 0004 0571 4942grid.416846.9Section of Pediatric Pulmonology, Institute of Pulmonary Medicine, St. Luke’s Medical Center, Quezon City, Philippines
| | - Jacqueline Austine U. Uy
- 0000 0004 0571 4942grid.416846.9Section of Pediatric Radiology, Institute of Radiology, St. Luke’s Medical Center, Bonifacio Global City, Taguig City, Philippines
| | - Timothy Reynold U. Lim
- 0000 0004 0571 4942grid.416846.9Section of Pediatric Radiology, Institute of Radiology, St. Luke’s Medical Center, Quezon City, Philippines
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Dobler CC. Screening strategies for active tuberculosis: focus on cost-effectiveness. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:335-47. [PMID: 27418848 PMCID: PMC4934456 DOI: 10.2147/ceor.s92244] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
In recent years, there has been renewed interest in screening for active tuberculosis (TB), also called active case-finding (ACF), as a possible means to achieve control of the global TB epidemic. ACF aims to increase the detection of TB, in order to diagnose and treat patients with TB earlier than if they had been diagnosed and treated only at the time when they sought health care because of symptoms. This will reduce or avoid secondary transmission of TB to other people, with the long-term goal of reducing the incidence of TB. Here, the history of screening for active TB, current screening practices, and the role of TB-diagnostic tools are summarized and the literature on cost-effectiveness of screening for active TB reviewed. Cost-effectiveness analyses indicate that community-wide ACF can be cost-effective in settings with a high incidence of TB. ACF among close TB contacts is cost-effective in settings with a low as well as a high incidence of TB. The evidence for cost-effectiveness of screening among HIV-infected persons is not as strong as for TB contacts, but the reviewed studies suggest that the intervention can be cost-effective depending on the background prevalence of TB and test volume. None of the cost-effectiveness analyses were informed by data from randomized controlled trials. As the results of randomized controlled trials evaluating different ACF strategies will become available in future, we will hopefully gain a better understanding of the role that ACF can play in achieving global TB control.
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Affiliation(s)
- Claudia Caroline Dobler
- Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
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Abstract
BACKGROUND Response to treatment may be useful for diagnostic confirmation of childhood tuberculosis (TB). We aimed to evaluate time to symptom resolution in children treated for pulmonary TB. METHODS We compared pulmonary TB cases and noncases, classified by a published diagnostic algorithm, in South African children younger than 2. TB treatment was prescribed independently on clinical grounds. We analyzed independent determinants of baseline symptom resolution by Cox regression. RESULTS One hundred and ninety-one symptomatic children, median age 12 months, were prescribed for TB treatment. Chest radiograph features of TB were associated with longer time to resolution of cough (adjusted hazard ratio, AHR 0.31), wheeze (AHR 0.26) and failure to thrive (AHR 0.41), (all P < 0.05). However, median duration of baseline cough (63 vs. 70 days, P = 0.98), wheeze (62 vs. 68 days, P = 0.87) and failure to thrive (76 vs. 66 days, P = 0.59) did not differ in TB cases (n = 48) versus noncases (n = 46). CONCLUSIONS Baseline symptoms take more than 60 days to resolve in the majority of young children after starting TB treatment. Furthermore, since time to resolution does not differentiate TB cases from noncases; clinical response to treatment is not an appropriate diagnostic criterion for pediatric trials of TB diagnostics, drugs and vaccines.
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9
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Triasih R, Robertson CF, Duke T, Graham SM. A prospective evaluation of the symptom-based screening approach to the management of children who are contacts of tuberculosis cases. Clin Infect Dis 2014; 60:12-8. [PMID: 25270649 DOI: 10.1093/cid/ciu748] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Child tuberculosis contact screening and management can enhance case finding and prevent tuberculosis disease. It is universally recommended but rarely implemented in tuberculosis-endemic settings. The World Health Organization (WHO)-recommended symptom-based screening approach could improve implementation but has not been prospectively evaluated. METHODS We conducted a cohort study of children who were close contacts of pulmonary tuberculosis patients in Indonesia from August 2010 to December 2012. We performed clinical assessment, tuberculin skin test, and chest radiography in all eligible children irrespective of symptoms at baseline. Mycobacterial culture and Xpert MTB/RIF assay were performed on sputum from children with persistent symptoms of suspected tuberculosis. Children were managed according to WHO guidelines and were prospectively followed for 12 months. RESULTS A total of 269 child contacts of 140 index cases were evaluated. At baseline, 21 (8%) children had tuberculosis diagnosed clinically; an additional 102 (38%) had evidence of infection without disease. Of children with any tuberculosis-related symptoms at baseline, 21% had tuberculosis diagnosed compared with none of the asymptomatic children (P < .001). After 12 months of follow-up, none of the 99 eligible young child contacts (<5 years) who received isoniazid preventive therapy (IPT) had developed disease compared with 4 of 149 (2.6%) asymptomatic older children who did not receive IPT. CONCLUSIONS Symptom-based screening is an effective and simple approach to child tuberculosis contact management that can be implemented at the primary healthcare level.
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Affiliation(s)
- Rina Triasih
- Department of Pediatrics, Dr Sardjito Hospital and Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia Centre for International Child Health, University of Melbourne Department of Paediatrics
| | - Colin F Robertson
- Department of Respiratory Medicine Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Australia
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne Department of Paediatrics Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Australia
| | - Stephen M Graham
- Centre for International Child Health, University of Melbourne Department of Paediatrics Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Australia International Union Against Tuberculosis and Lung Disease, Paris, France
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Tameris MD, Hatherill M, Landry BS, Scriba TJ, Snowden MA, Lockhart S, Shea JE, McClain JB, Hussey GD, Hanekom WA, Mahomed H, McShane H. Safety and efficacy of MVA85A, a new tuberculosis vaccine, in infants previously vaccinated with BCG: a randomised, placebo-controlled phase 2b trial. Lancet 2013; 381:1021-8. [PMID: 23391465 PMCID: PMC5424647 DOI: 10.1016/s0140-6736(13)60177-4] [Citation(s) in RCA: 754] [Impact Index Per Article: 68.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND BCG vaccination provides incomplete protection against tuberculosis in infants. A new vaccine, modified Vaccinia Ankara virus expressing antigen 85A (MVA85A), was designed to enhance the protective efficacy of BCG. We aimed to assess safety, immunogenicity, and efficacy of MVA85A against tuberculosis and Mycobacterium tuberculosis infection in infants. METHODS In our double-blind, randomised, placebo-controlled phase 2b trial, we enrolled healthy infants (aged 4–6 months) without HIV infection who had previously received BCG vaccination. We randomly allocated infants (1:1), according to an independently generated sequence with block sizes of four, to receive one intradermal dose of MVA85A or an equal volume of Candida skin test antigen as placebo at a clinical facility in a rural region near Cape Town, South Africa. We actively followed up infants every 3 months for up to 37 months. The primary study outcome was safety (incidence of adverse and serious adverse events) in all vaccinated participants, but we also assessed efficacy in a protocol-defined group of participants who received at least one dose of allocated vaccine. The primary efficacy endpoint was incident tuberculosis incorporating microbiological, radiological, and clinical criteria, and the secondary efficacy endpoint was M tuberculosis infection according to QuantiFERON TB Gold In-tube conversion (Cellestis, Australia). This trial was registered with the South African National Clinical Trials Register (DOH-27-0109-2654) and with ClinicalTrials.gov on July 31, 2009, number NCT00953927. FINDINGS Between July 15, 2009, and May 4, 2011, we enrolled 2797 infants (1399 allocated MVA85A and 1398 allocated placebo). Median follow-up in the per-protocol population was 24·6 months (IQR 19·2–28·1), and did not differ between groups. More infants who received MVA85A than controls had at least one local adverse event (1251 [89%] of 1399 MVA85A recipients and 628 [45%] of 1396 controls who received the allocated intervention) but the numbers of infants with systemic adverse events (1120 [80%] and 1059 [76%]) or serious adverse events (257 [18%] and 258 (18%) did not differ between groups. None of the 648 serious adverse events in these 515 infants was related to MVA85A. 32 (2%) of 1399 MVA85A recipients met the primary efficacy endpoint (tuberculosis incidence of 1·15 per 100 person-years [95% CI 0·79 to 1·62]; with conversion in 178 [13%] of 1398 infants [95% CI 11·0 to 14·6]) as did 39 (3%) of 1395 controls (1·39 per 100 person-years [1·00 to 1·91]; with conversion in 171 [12%] of 1394 infants [10·6 to 14·1]). Efficacy against tuberculosis was 17·3% (95% CI −31·9 to 48·2) and against M tuberculosis infection was −3·8% (–28·1 to 15·9). INTERPRETATION MVA85A was well tolerated and induced modest cell-mediated immune responses. Reasons for the absence of MVA85A efficacy against tuberculosis or M tuberculosis infection in infants need exploration. FUNDING Aeras, Wellcome Trust, and Oxford-Emergent Tuberculosis Consortium (OETC).
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Affiliation(s)
- Michele D Tameris
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
- Correspondence to: Dr Michele D Tameris, South African Tuberculosis Vaccine Initiative (SATVI), Brewelskloof Hospital, Haarlem Street, Worcester 6850, South Africa
| | - Mark Hatherill
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | | | - Thomas J Scriba
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | | | - Stephen Lockhart
- Oxford-Emergent Tuberculosis Consortium, Wokingham, Berkshire, UK
- Emergent Product Development UK, Wokingham, Berkshire, UK
| | | | | | - Gregory D Hussey
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
- Vaccines for Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Willem A Hanekom
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Hassan Mahomed
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
- Department of Health, Western Cape and Division of Community Health, Stellenbosch University, Stellenbosch, South Africa
| | - Helen McShane
- Jenner Institute, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Prof Helen McShane, University of Oxford, Jenner Institute, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
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Tameris M, McShane H, McClain JB, Landry B, Lockhart S, Luabeya AK, Geldenhuys H, Shea J, Hussey G, van der Merwe L, de Kock M, Scriba T, Walker R, Hanekom W, Hatherill M, Mahomed H. Lessons learnt from the first efficacy trial of a new infant tuberculosis vaccine since BCG. Tuberculosis (Edinb) 2013; 93:143-9. [PMID: 23410889 PMCID: PMC3608032 DOI: 10.1016/j.tube.2013.01.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Revised: 01/09/2013] [Accepted: 01/21/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND New tuberculosis (TB) vaccines are being developed to combat the global epidemic. A phase IIb trial of a candidate vaccine, MVA85A, was conducted in a high burden setting in South Africa to evaluate proof-of-concept efficacy for prevention of TB in infants. OBJECTIVE To describe the study design and implementation lessons from an infant TB vaccine efficacy trial. METHODS This was a randomised, controlled, double-blind clinical trial comparing the safety and efficacy of MVA85A to Candin control administered to 4-6-month-old, BCG-vaccinated, HIV-negative infants at a rural site in South Africa. Infants were followed up for 15-39 months for incident TB disease based on pre-specified endpoints. RESULTS 2797 infants were enrolled over 22 months. Factors adversely affecting recruitment and the solutions that were implemented are discussed. Slow case accrual led to six months extension of trial follow up. CONCLUSION The clinical, regulatory and research environment for modern efficacy trials of new TB vaccines are substantially different to that when BCG vaccine was first evaluated in infants. Future infant TB vaccine trials will need to allocate sufficient resources and optimise operational efficiency. A stringent TB case definition is necessary to maximize specificity, and TB case accrual must be monitored closely.
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Affiliation(s)
- Michele Tameris
- South African TB Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine (IIDMM) and School of Child and Adolescent Health, University of Cape Town, Brewelskloof Hospital, Haarlem Street, Worcester, Western Cape 6850, South Africa
| | - Helen McShane
- Jenner Institute, University of Oxford, United Kingdom
| | | | | | | | - Angelique K.K. Luabeya
- South African TB Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine (IIDMM) and School of Child and Adolescent Health, University of Cape Town, Brewelskloof Hospital, Haarlem Street, Worcester, Western Cape 6850, South Africa
| | - Hennie Geldenhuys
- South African TB Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine (IIDMM) and School of Child and Adolescent Health, University of Cape Town, Brewelskloof Hospital, Haarlem Street, Worcester, Western Cape 6850, South Africa
| | - Jacqui Shea
- Oxford Emergent Tuberculosis Consortium, United Kingdom
| | - Gregory Hussey
- Vaccines for Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medical Microbiology, University of Cape Town, South Africa
| | - Linda van der Merwe
- South African TB Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine (IIDMM) and School of Child and Adolescent Health, University of Cape Town, Brewelskloof Hospital, Haarlem Street, Worcester, Western Cape 6850, South Africa
| | - Marwou de Kock
- South African TB Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine (IIDMM) and School of Child and Adolescent Health, University of Cape Town, Brewelskloof Hospital, Haarlem Street, Worcester, Western Cape 6850, South Africa
| | - Thomas Scriba
- South African TB Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine (IIDMM) and School of Child and Adolescent Health, University of Cape Town, Brewelskloof Hospital, Haarlem Street, Worcester, Western Cape 6850, South Africa
| | | | - Willem Hanekom
- South African TB Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine (IIDMM) and School of Child and Adolescent Health, University of Cape Town, Brewelskloof Hospital, Haarlem Street, Worcester, Western Cape 6850, South Africa
| | - Mark Hatherill
- South African TB Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine (IIDMM) and School of Child and Adolescent Health, University of Cape Town, Brewelskloof Hospital, Haarlem Street, Worcester, Western Cape 6850, South Africa
| | - Hassan Mahomed
- South African TB Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine (IIDMM) and School of Child and Adolescent Health, University of Cape Town, Brewelskloof Hospital, Haarlem Street, Worcester, Western Cape 6850, South Africa
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12
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Rustomjee R, Mcleod R, Hanekom W, Steel G, Mahomed H, Hawkridge A, Welte A, Sinanovic E, Loots G, Grobler A, Mvusi L, Gray G, Hesseling A, Ginsberg A, Lienhardt C, Shea J, Tong X, Lockhart S, Churchyard G. Key issues in the clinical development and implementation of TB vaccines in South Africa. Tuberculosis (Edinb) 2012; 92:359-64. [DOI: 10.1016/j.tube.2012.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Accepted: 05/04/2012] [Indexed: 11/29/2022]
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13
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Bechah Y, Mege JL, Raoult D. Cross-protection among Rickettsia species and subspecies in a guinea pig model of cutaneous infection. Comp Immunol Microbiol Infect Dis 2012; 35:551-6. [PMID: 22784931 DOI: 10.1016/j.cimid.2012.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 06/12/2012] [Accepted: 06/14/2012] [Indexed: 10/28/2022]
Abstract
Pathogenic rickettsiae of the spotted fever group (SFG) induce skin lesions called "eschars" at the sites of arthropod bites. We recently described a guinea pig model based on eschar formation to predict the eventual pathogenicity of new Rickettsia species, and in this study, we used the model to study cross-protection among SFG Rickettsia species and subspecies. We showed that the intradermal inoculation of guinea pigs with Rickettsia conorii subsp. conorii significantly reduced, but not completely prevented, the number of eschars after sub-challenges with the same pathogen (P=0.0004). The same effect was also observed for other subspecies of the R. conorii complex. Additionally, the bacterial load in the eschars was significantly lower in immunized animals than in naïve animals. No protection was observed when sub-challenges were performed with other Rickettsia species, such as R. africae, R. sibirica subsp. mongolitimonae, R. aeschlimannii and R. massiliae. Our data suggest that patients may experience several episodes of infection with related or with the same species of Rickettsia. Moreover, the absence of cross-protection between Rickettsia species may explain the co-existence of two or more tick-borne rickettsioses in the same geographic areas.
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Affiliation(s)
- Yassina Bechah
- Unité de Recherche sur les Maladies Infectieuses Transmissibles et Emergentes, Aix-Marseille Université, CNRS UMR 7278, INSERM U1095, Faculté de Médecine, 27 Boulevard Jean Moulin, 13385 Marseille Cedex 05, France
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